PATRICK A. MEERE, M.D. 530 First Avenue, Suite 5J New York, New York 10016 T 212.263.2366 F 212.263.2365 info@drpatrickmeere.com www.drpatrickmeere.com KNEE SOCIETY SCORE Patient s name (or ref) Clinician s name (or ref) Patient s d.o.b. PART 1 - KNEE SCORE PAIN O None O Mild/Occasional O Mild - Stairs Only O Mild - Walking and Stairs O Moderate - Occasional O Moderate - Continual O Severe TOTAL RANGE OF FLEXION O 0-5 O 6-10 O 11-15 O 16-20 O 21-25 O 26-30 O 31-35 O 36-40 O 41-45 O 46-50 O 51-55 O 56-60 O 61-65 O 66-70 O 71-75 O 76-80 O 81-85 O 86-90 O 91-95 O 96-100 O 101-105 O 106-110 O 111-115 O 116-120 O 121-125 FLEXION CONTRACTURE - if Present O 5-10 O 10-15 O 16-20 O >20 EXTENSION LAG O <10 O 10-20 O >20 ALIGNMENT - Varus & Valgus O 0 O 1 O 2 O 3 O 4 O 5-10 O 11 O 12 O 13 O 14 O 15 O Over 15 STABILITY - Maximum movement in any position ANTERO-POSTERIOR O <5mm O 5-10mm O 10+mm FINAL KNEE SCORE IS: MEDIOLATERAL O <5 O 6-9 O 10-14 O 15 GRADING FOR THE KNEE SOCIETY SCORE SCORE 80-100 - Excellent SCORE 70-79 - Good SCORE 60-69 - Fair SCORE BELOW 60 - Poor Page 1 of 2
PART 2 - FUNCTION WALKING O Unlimited O >10 blocks O 5-10 blocks O <5 blocks O Housebound O Unable STAIRS O Normal Up and down O Normal Up down with rail O Up and down with rail O Up with rail, down unable O Unable WALKING AIDS USED O None used O Use of Cane/Walking stick deduct O Two Canes/sticks O Crutches or frame FUNCTION SCORE (KNEE SOCIETY SCORE) IS: Page 2 of 2
PATRICK A. MEERE, M.D. 530 First Avenue, Suite 5J New York, New York 10016 T 212.263.2366 F 212.263.2365 info@drpatrickmeere.com www.drpatrickmeere.com KNEE INJURY AND OSTEOARTHRITIS OUTCOME SCORE (KOOS) Patient s name (or ref) Clinician s name (or ref) Patient s d.o.b. INSTRUCTIONS: This survey asks for your view about your knee. This information will help us keep track of how you feel about your knee and how well you are able to do your usual activities. Answer every question by ticking the appropriate box. If you are unsure about how to answer a question, please give the best answer you can. SYMPTOMS These questions should be answered thinking of your knee symptoms during the last week. S1. Do you have swelling in your knee? Never Rarely Sometimes Often Always S2. Do you feel grinding, hear clicking or any other type of noise when your knee moves? S3. Does your knee catch or hang up when moving? S4. Can you straighten your knee fully? S5. Can you bend your knee fully? STIFFNESS The following questions concern the amount of joint stiffness you have experienced during the last week in your knee. Stiffness is a sensation of restriction or slowness in the ease with which you move your knee joint. S6. How severe is your knee joint stiffness after first wakening in the morning? S7. How severe is your knee stiffness after sitting, lying or resting PAIN P1. How often do you experience knee pain? Never Monthly Weekly Daily Always What amount of knee pain have you experienced the last week during the following activities? P2. Twisting/pivoting on your knee None Mild Moderate P3. Straightening knee fully Page 1 of 3
PAIN CONTINUED P4. Bending knee fully P5. Walking on flat surface P6. Going up or down stairs P7. At night while in bed P8. Sitting or lying P9. Standing upright FUNCTION, DAILY LIVING The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee. Al. Descending stairs A2. Ascending stairs For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee. A3. Rising from sitting A4. Standing A5. Bending to floor/pick up an object A6. Walking on flat surface A7. Getting in/out of car None Mild Moderate Severe Extreme A8. Going Shopping A9. Putting on socks/stockings A10. Rising from bed A11. Taking off socks/stockings A12. Lying in bed (turning over, maintaining knee position) Page 2 of 3
FUNCTION, DAILY LIVING CONTINUED A13. Getting in/out of bath A14. Sitting A15. Getting on/off toilet For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc) A17. Light domestic duties (cooking, dusting, etc) FUNCTION, SPORTS AND RECREATIONAL ACTIVITIES The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your knee. SP1. Squatting SP2. Running SP3. Jumping SP4. Twisting/pivoting on your injured knee SP5. Kneeling QUALITY OF LIFE Q1. How often are you aware of your knee problem? Never Monthly Weekly Daily Constantly Q2. Have you modified your life style to avoid potentially damaging activities to your knee? Not at all Mildly Moderately Severely Totally Q3. How much are you troubled with lack of confidence in your knee? Not at all Mildly Moderately Severely Extremely Q4. In general, how much difficulty do you have with your knee? None Mild Moderately Severe Extreme KNEE INJURY & OSTEOARTHRITIS OUTCOME Page 3 of 3